Evolving Practice in Management of Pelvic-Acetabular Trauma: COVID-19 Experience From a Tertiary Referral Centre in the UK.

Introduction The United Kingdom was one of the hardest-hit countries during the COVID-19 Pandemic. The UK government announced three national lockdowns to control the spread of the coronavirus and prevent the NHS from getting overburdened with COVID-19 related attendances. Two of the most significant peaks in terms of COVID-19 related hospitalizations and COVID-19 related deaths were in Summer 2020 (corresponding to lockdown 1, which was in effect from 26th March to 26th May 2020) and early 2021 (corresponding to lockdown 3, which was in effect 6th January to 8th March 2021). During this time, a significant proportion of NHS resources was being diverted towards the treatment of COVID-19 patients. Measures were being taken to prevent unnecessary hospitalizations and reduce patient contact. These included but were not limited to measures to reduce attendances to Emergency departments, introducing telemedicine clinics, and pausing elective services.  Our hospital is a Major Trauma Centre providing Tertiary Pelvic trauma service to the Greater Manchester area and the North West of England. We conducted this retrospective comparative study to compare the trends in presentation and Management of Pelvic trauma and identify trends in how these changed throughout the pandemic. We want to share these insights with our readers. Methodology We conducted a retrospective comparative study by comparing two cohorts of patients, patients presenting to the Pelvic Trauma service during Lockdown 1 and Lockdown 3 in the UK, named Group A and Group B, respectively. Data on patient demographics, injuries, and their management was identified from the Electronic Patient Record System. The data analysis was carried out with the aid of Stata/IC version 16.1. using descriptive Statistics. Results Group A contained 19 patients, with a mean age of 66.9 years. Group B contained 23 patients with a mean age of 67.4 years. There was no statistically significant difference in these patients' population demographics, injury patterns, and management (operative vs conservative). However, there was an absolute reduction in the complication rate from Group A to Group B of 17.2% (26.3% vs 9.1%). The higher complication rate during Lockdown 1 can be explained by conservatively managing Pelvic and Acetabular Fractures that would have been eligible for fixation, had COVID-19 not been a factor. Conclusions Within the limitations of our study, it appears that operatively managing a carefully selected cohort of acute Pelvic Trauma patients with proper precautions was safe and effective. It is unclear whether there was an added benefit to having a higher threshold to operate and adopting the watch-and-wait policy in Lockdown 1. We recommend continuing to follow the current evidence and fix these fractures early.

Two-Stage Revision Hip Arthroplasty with or without the Use of an Interim Spacer for Managing Late Prosthetic Infection: A Systematic Review of the Literature.

The aim of the present paper was to identify, appraise, and synthesize the available evidence on two-stage revision hip arthroplasty with or without the use of an interim spacer for managing late prosthetic infection. The review methodology was designed by referencing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist and flow diagram, and a Population, Intervention, Comparator, Outcomes and Study (PICOS) design framework was used to search for studies to incorporate within the review. Two independent investigators were involved in searching for relevant articles that fulfilled the inclusion criteria for the study. Critical appraisal of the selected articles was carried out using the relevant Critical Appraisal Skills Programme checklists. From an initial pool of 125 articles, four studies satisfied the inclusion criteria and quality assessment and were included for final review. Two patient groups were identified from within the selected studies: spacer and non-spacer. Both groups were assessed in terms of functional outcome, infection cure rates, and technical difficulties encountered during treatment. Better functional outcome was reported in the spacer group, both in the interim period between the two stages and after completion of treatment. The use of spacers reduced operative difficulty during the second stage and accelerated patient discharge. Reinfection and infection persistence rates were higher in the non-spacer group. Within the spacer group, articulated spacers performed better in all parameters. The results of this review reinforce the available evidence supporting the use of interim hip spacers in revision hip arthroplasty for managing prosthetic infection and also indicate that articulated hip spacers could be an attractive option going forward.

Management of acetabular fractures in elderly patients.

Management of acetabular fractures in elderly patients is challenging. The challenges arise due to associated medical comorbidities, poor bone quality and comminution. There are multiple modalities of treatment. the exact algorithms or treatment remain undefined. Treatment is still based on experience and some available evidence. The options include conservative treatment, percutaneous fixation, open reduction internal fixation and the acute fix and replace procedure. There is a well recognised risk of each treatment option. We present a narrative review of the relevant available evidence and our treatment principles based on experience from a regional tertiary pelvic-acetabular fracture service.

The outcome of scapulothoracic arthrodesis using cerclage wires, plates, and allograft for facioscapulohumeral dystrophy.

BACKGROUND: Scapulothoracic arthrodesis is a recognized treatment for impaired shoulder function in patients with facioscapulohumeral dystrophy (FSHD) and is traditionally performed with autograft. The purpose of the study was to report our experience with scapulothoracic arthrodesis in patients with FSHD using allograft, rather than autograft, with particular respect to the effect of fusion on preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores; forced vital capacity (FVC); and complications. MATERIALS AND METHODS: The early results of 14 consecutive scapulothoracic arthrodeses in FSHD patients with cerclage wires, plates, and allograft (fresh-frozen femoral heads) are reported. DASH scores were recorded preoperatively and 6 months postoperatively. Preoperative and 6-month FVCs were compared. The surgical technique is described. RESULTS: Eleven patients underwent 14 fusions. The mean follow-up period was 29 months (range, 6-50 months). Forward flexion improved from 70° to 115° (P = .001) and abduction from 68° to 109° (P = .007). The DASH score improved from 48 points to 34 points (P = .005). FVC decreased from 98% to 92% of predicted (P = .021), although this was not clinically significant. One patient required revision for nonunion, and metalwork was removed in 5 scapulae. A postoperative chest infection developed in 1 patient and a pleural effusion in another. One brachial plexus palsy occurred, which had almost completely resolved by 27 months postoperatively. CONCLUSION: Scapulothoracic arthrodesis can be performed successfully with allograft. The nonunion and complication rates are similar to those in the existing literature. A small decrease in FVC does occur but not to a clinically significant level.

Observational analysis of BOA free-papers (2001): from presentation to publication and comparison with the American Academy of Orthopaedic Surgeons (AAOS).

AIM: The objectives of this study were to: determine the presentation to publication conversion rate (PPCR) in peer-reviewed indexed journals of free papers and posters presented at 12-14th September 2001 British Orthopaedic Association (BOA) annual meeting and to compare the publication rate with the American Academy of Orthopaedic Surgeons (AAOS) meeting in 2001. METHODOLOGY: We looked at all presentations including both podium and poster presentations at British Orthopaedic Association meeting held in 2001 and assessed for subsequent publication as full-text article with a fixed PubMed search protocol. Once the abstract was identified as being published, we noted the name of the journal, citation, and time to presentation. The level of evidence was assigned for each abstract along the guidelines published by the centre for evidence-based medicine, Oxford, UK. This conversion rate was compared with the presentation to publication rate for the AAOS meeting in 2001. RESULTS: A total of 179 abstracts were presented at the 2001 BOA meeting. 65 of these were published as full-text articles in 30 different journals. The overall publication rate was 36.3%. The publication rate of the papers presented at AAOS annual meeting 2001 was 49% (367/756). The mean time from presentation to publication was 18.6 months (±9.4 months). Three fourths of them were published after 2 years of presentations (63% for AAOS). Majority of studies were either level III or IV. 14 full-text articles were published in Journal of Bone and Joint Surgery British (JBJS Br) and 8 in the Injury Journal. CONCLUSIONS: This is the first study reporting the publication rate of presentations for BOA meeting and comparing it with the publication rate of AAOS meeting in 2001. The publication rate of BOA presentations is much lower than the AAOS meeting. We believe the publication rate is an important tool in judging the quality of research work and the reputation of a scientific meeting with higher conversion rates suggesting better quality. Thus, more stringent selection criteria need to be introduced so that the selected abstracts can withstand peer-view for publication as full-text articles.

Successful treatment of sternal non-union by ultrasound.

We report a case of sternal non-union after open aortic valve replacement surgery in a 48-year-old man. The sternotomy was repaired using stainless steel wires and later, 'flexigrip' cables. He presented to us six months later complaining of persistent pain in the sternotomy site. CT-scan confirmed a sternal non-union. After consultation with the ultrasound device, and aortic valve manufacturers, we established that there was no previous similar reported case, but there were no contraindications to use of ultrasound. We started treatment using non-invasive pulsed ultrasound therapy. The non-union healed clinically and radiologically within four months. This is the first report of treatment of sternal non-union using low intensity ultrasound. This therapy appears safe and can be used as a first line of treatment for adequately stabilized sternal non-unions.

Correction of neuromuscular scoliosis in patients with preexisting respiratory failure.

STUDY DESIGN: A prospective observational study in scoliosis patients who were on noninvasive night ventilation for respiratory failure. OBJECTIVE: To report the results of spinal deformity correction in a group of patients with progressive scoliosis and rare forms of muscular dystrophy/myopathy with respiratory failure who were on nocturnal ventilatory support at the time of surgery. SUMMARY OF BACKGROUND DATA: This is the first study on the results of deformity correction in a series of patients on ventilatory support. MATERIALS AND METHODS: Eight patients (6 males, 2 females) presented with progressive scoliosis and respiratory failure. The mean age at surgery was 12 years (range, 8-15 years). The mean follow-up was 48 months (range, 12-80 months). Outcome measures include lung function (spirometry), overnight pulse oximetry, Cobb angles, duration of stay in Intensive care (ICU), and the total hospital stay. RESULTS: The mean stay in the ICU was 2.7 days (range, 2-5 days). The mean hospital stay was 14.2 days (range, 10-21 days). The mean preoperative Cobb angle was 70.2 degrees (55 degrees -85 degrees ). This changed to 32 degrees (16 degrees -65 degrees ) after surgery (P = 0.0002). The mean vital capacity at the time of surgery was 20% (range, 13%-28%). The mean vital capacity of patients at last follow-up was 18% (range, 10%-31%). The desaturation noted on the preventilation overnight oximetry was reversed by nocturnal ventilation. All patients recovered well following surgery with no major cardiac or pulmonary complications. CONCLUSION: Patients with preexisting respiratory failure on nocturnal noninvasive ventilation can be safely operated for deformity correction. This can help to significantly improve their quality of life.

Spondylocostal dysostosis: thirteen new cases treated by conservative and surgical means.

STUDY DESIGN: Prospective assessment of a cohort of patients affected by spondylocostal dysostosis. OBJECTIVE: To report on the results of conservative and operative management of spondylocostal dysostosis and, based on this, to propose an assessment and treatment protocol for the condition. SUMMARY OF BACKGROUND DATA: Spondylocostal dysostosis and spondylothoracic dysostosis are subtypes of Jarcho-Levin syndrome, a hereditary condition manifested by vertebral body and related rib malformations. Mortality prevails in spondylothoracic dysostosis because of more severe respiratory compromise. METHODS: Details of prenatal and postnatal diagnosis, history, and management of 13 patients with spondylocostal dysostosis are presented. All patients were treated postnatally with repeated chest physiotherapy. Two patients refractory to conservative treatment underwent surgical intervention: the first had a chest wall reconstruction via a latissimus dorsi flap, the second a posterior spinal instrumented fusion for progressive scoliosis. RESULTS: Prenatal ultrasound in 4 of 13 cases showed full details of vertebral and rib anomalies. Thoracic and lumbar hemivertebrae were most common, leading to congenital scoliosis in 10 of 13 cases. A number of extraskeletal abnormalities were also identified. At an average follow-up of 4.5 years, the survival rate was 100% with a remarkable decrease of the rate of respiratory complications. Surgical treatment in selected cases led to satisfactory results. CONCLUSIONS: Prenatal diagnosis of spondylocostal dysostosis allows exclusion of spondylothoracic dysostosis and aids genetic counseling in quantifying the risk to siblings. Postnatally, prompt management of these patients with physiotherapy leads to prolonged survival. Surgical intervention may then be indicated to stabilize chest wall or spine deformities, with promising results.